Fillable Enrolment Form for Extended Recreation and Culture Programs (City of Ottawa)

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Enrolment Form for Extended Recreation and Culture Programs (City of Ottawa)

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1
Enrolment Form
for Extended Recreation and Culture Programs
Re: Department of Recreation, Cultural and Facility Services, Policy 8.5.0 Conditions of Enrolment
Please take the time to complete this form carefully. This information is personal and confidential, and with the exception of certain
situations set out in this form, will only be used by Recreation, Cultural and Facility Services (RCFS) staff to ensure that proper care and
attention is given the health and safety of the participant.
Program Information
Program/Activity Name:
Barcode (if available):
Date(s) of Program (DD/MM/YYYY):
Location of Program:
Participant Information
Last Name: Middle Initial: First Name:
Home Telephone:
Gender:
Date of Birth (DD/MM/YYYY):
School/Grade (where applicable):
Address:
City: Province: Postal Code: Age:
For Applicable Programs/Activities: Can the participant swim in deep water (water over their head) without assistance and without the
use of a life jacket for 25 meters? Swim test may be required. Participants using lifejackets will not be permitted to swim in deep water.
Yes No
Last swimming level achieved (if known):
May we have permission to take the participant's photograph or video, which may be used on the City of Ottawa's public website, in
print, electronic media and/or community newspapers for the promotion of City program and services?
Yes No
Parent(s)/Guardian(s)/Agency Information
First & Last Name of Parent/Guardian:
Relationship to Participant:
Cell Phone:
Home Phone:
Work Phone:
E-mail
First & Last Name of Parent/Guardian:
Relationship to Participant:
Cell Phone:
Home Phone:
Work Phone:
E-mail
First & Last Name of Emergency Contact:
Relationship to Participant:
Cell Phone:
Home Phone:
Work Phone:
E-mail
2
Authorized Participant Pick-up
List the full name of people(s) who are permitted to pick up the participant. The person picking up the participant may be asked to show
picture I.D. daily. Persons not listed below will not be permitted to pick up the participant:
1.
2.
3.
4.
The parent(s), guardian(s) and emergency contact(s) as named above are permitted to pick up the participant.
If there are any access or custody restrictions, please provide legal documentation to the Full Time Staff.
Authorized Program Arrival and Departure
Arrival – The participant will:
Be dropped off Arrive on their own
Departure – The participant will:
Be picked up Leave on their own
At what time:
Walk Bike Other
Note: Supervision will not be provided outside of designated registered program times. Participants are to arrive and depart solely
during the times of the registered program as outlined in the registration confirmation.
(time authorized to leave)
3
Health/Special Needs Information
1. Is the participant taking any medication (oral, inhaler, injection, auto-injectors, prescription, non-prescription)?
Yes No
If yes, please complete the Medication Administration Request Form
2. Does the participant have any life-threatening allergies?
Yes No
If yes, please specify:
3. Does the participant have any disease or condition for which they are receiving on-going medical treatment?
Yes No
If yes, please specify:
5. Does the participant have a medical condition or disability (physical, mental health or developmental) that may affect their
participation or integration into the program?
Yes No
If yes or if registered in an Inclusive Recreation program, please note below AND complete APPENDIX A.
If YES, it is necessary for you contact the Admin Clerk, Inclusive Recreation Unit at (613) 580-2424 extension 29283 to discuss program
and support requirements prior to registration.
Please allow two weeks prior to program start date. For detailed contact information please refer to www.ottawa.ca
.
If yes, please specify:
4. Does the participant receive support at school or have an accommodation?
Yes No
If yes, please specify:
If yes, please complete the Medication Administration Request Form
Permission to Participate, Assumption of Risks, Waiver of Liability & Indemnification Obligation
Please read carefully. By signing this document, you will be assuming risks and waiving certain rights.
Permission to Participate:
I, as the parent or legal guardian of the participant named above, confirm that this individual is a minor pursuant to the Age of Majority &
Accountability Act, and provide permission for them to participate in the program or activity noted above. I also confirm that I have been
provided with the Conditions of Enrolment for this activity, and agree with these conditions.
Assumption of Risk and Waiver of Liability: COVID-19
When children from multiple families attend a recreation program, there is an increased risk of the COVID-19 virus coming into the
program. Children who are infected with the COVID-19 virus are more likely than adults to have very mild infections or to have no
symptoms at all, but these children can still transmit the infection to other children and to adults at the program. This means that children
can bring home an infection acquired in a program and put other persons at risk. The program screening process will not detect infected
children or adults who do not have symptoms at the time of screening.
•All individuals, including participants, staff, and visitors must be screened daily upon arrival at program setting prior to entry.
•For COVID-19 specifically, anyone who fits any of the criteria below will not be allowed into the facility/program and will needto self-
isolate for a period of 14 days or as directed below related to management of symptoms:
•Symptoms outlined below, from the Ministry of Health's `COVID-19 Reference Document for Symptoms':
1. Fever (temperature of 37.8 degrees C or greater), new or worsening cough, shortness of breath.
2. Other symptoms - sore throat, difficulty swallowing, new olfactory or taste disorder(s), nausea, vomiting, diarrhea,
abdominal pain, runny nose, or nasal congestion (in absence of underlying reason for these symptoms such as
seasonalallergies, postnasal drip, etc.).
3. Other signs - clinical or radiological evidence of pneumonia.
4
Personal information collected on this form will be used by authorized Recreation, Culture & Facility staff for the purposes of
administering and managing the Extended Recreation and Cultural Programs. Questions about the collection and use of information for
sharing information with other city departments may be addressed to RCFS/DGLCIRisk@ottawa.ca. All other inquiries can be addressed by
contacting 3-1-1.
I hereby agree to indemnify and save harmless the City of Ottawa and its employees, officials, agents, and volunteers from any and all
liability for any property damage or personal injury to any third party resulting from the participant’s participation in this program or
activity.
By signing below, I agree with the terms of the permission to participate, the assumption of risk, the waiver of liability, and the
indemnification set out above.
I fully understand that the program or activity for which I have enrolled the participant may involve personal risk, dangers, and hazards
that all participants are required to assume including but not limited to some risk of personal injury caused by physical activity or other
participants. Understanding this, I hereby accept on behalf of the participant all risks, dangers, and hazards as well as the possibility of
personal injury or other loss resulting from the participant’s participation in this program or activity. I agree to release, waive, and
discharge the City of Ottawa, as well as its employees, officials, agents, and volunteers, from all liability to me, and to the participant,
and to my heirs, executors and administrators, that we have, or may have in the future, for all loss or damage and from any claims or
demands for such loss or damage on account of personal illness, injury, and damage including death or property loss, however caused,
as a result of the participant’s participation in this program or activity.
Indemnification:
4. Atypical symptoms and signs - unexplained fatigue/malaise/myalgias, delirium (a serious medical condition thatinvolves
confusion, changes to memory, and odd behaviours), unexplained or increased number of falls, acutefunctional decline,
worsening of chronic conditions, chills, headaches, croup, conjunctivitis, multisystem inflammatoryvasculitis in children,
unexplained tachycardia (heart rate over 100 beats per minute), including age specific tachycardiafor children, decrease in
blood pressure, unexplained hypoxia (even if mild i.e. O2 sat <90%), lethargy and difficultyfeeding in infants (if no other
diagnosis).
5. Symptoms compatible with COVID-19 and in whom laboratory diagnosis of COVID-19 is inconclusive.
6. Travelled outside of Canada in the last 14 days.
If participants are displaying one or more symptoms of COVID-19, they will not be permitted into the program.
Parent/Guardian Printed Name
Participant Printed Name if 16 or 17 years of age
Parent/Guardian Signature Date (DD/MM/YYYY)
Date (DD/MM/YYYY)Participant Signature if 16 or 17 years of age
5
Enrolment Form - Appendix A
Please complete only if you answered "Yes" to question 5 in the "Health/Special Needs Information" section.
1. Does the participant require assistance with any of the following? Please be specific as to what accommodation is required.
a. Toileting:
b. Eating:
c. Dressing:
d. Vision / Hearing
e. Mobility:
uses a mobility device independently requires assistance
f. Ability to communicate:
Yes No
verbal non-verbal required supports (such as ASL, PEC's, Visual Schedule)
g. Participation:
Transitions
Changes to Routine
Motivation
Remaining with the Group
Following Instruction
Sensory Overload
h. Behaviour / Conduct:
Aggression toward self
Aggression toward others
Verbal Aggression
Physical Aggression
Ability to Control Emotions
Coping Skills (such as isolating themselves or running away)
2. The participant’s likes:
3. The participant’s dislikes/fears/or is triggered by:
4. What support does the participant receive at school?
Traditional Class
Traditional Class with Shared Support
Traditional Class with 1:1 Support
Specialized class
for Extended Recreation and Culture Programs
Re: Department of Recreation, Cultural and Facility Services, Policy 8.5.0 Conditions of Enrolment
If yes, do they:
Yes No
If yes:
Other:
Other:
6
6. Can you provide any additional information that would increase the success of participation?
5. What other agencies or service providers does the participant and/or family receive?
Funding
Occupational Therapy
Speech Therapy
Physiotherapy
Other:
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Enrolment Form for Extended Recreation and Culture Programs (City of Ottawa)

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Completed 4 September 2021

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